=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861329047
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIC M BRANCH LSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2026
-----------------------------------------------------
Last Update Date | 05/04/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2930 W GRAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-817-9858
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2930 W GRAND AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-4308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-603-8379
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 150.110200
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------